The people at St. Luke's Hospital in Kansas City, Mo., have gotten used to applying for-and winning-luscious awards.
Over the past two years they have been garlanded with, among others, the Missouri Excellence in Leadership in Medicine Award, the VHA Quality Leadership Award for Clinical Effectiveness, the Missouri Quality Award, the Archon Award (for nursing) and the Paragon Award (for good human resources practices).
Now they've won the 1997 National Quality Health Care Award, which will be presented Jan. 28 by the National Committee for Quality Health Care. The NCQHC is a coalition of hospitals, healthcare organizations, pharmaceutical companies and vendors to healthcare providers dedicated to defining and promoting quality healthcare. The group initiated the award in 1993.
The NCQHC also awarded a special mention to Shadyside Hospital in Pittsburgh for its congestive heart failure quality improvement project.
"This is a big deal," said G. Richard Hastings, chief executive officer of St. Luke's. "We always perceived we had quality, but we wanted peer review of quality. As a business strategy, quality was key to us."
Two-and-a-half years ago, St. Luke's started to look seriously at how it might inject quality improvement as a constant theme in hospital operations. Executives adopted principles from the Malcolm Baldrige quality award process using benchmarking goals.
As an operating strategy, they have tried to tie quality improvement to the hospital's financial performance, Hastings said. "We never have a financial report that we don't have a quality report. Because that's what we sell," he said.
The awards juggernaut has been part of the quality strategy. "It sensitizes people, raises expectations, validates processes and procedures, and allows us to aggregate," said Eugene Fibuch, M.D., an anesthesiologist and St. Luke's medical director for quality.
The awards themselves are not the point, said Sherry Toigo, the hospital's chief quality officer, but they lend focus to the goal.
"What we learned in applying for the Missouri Quality Award, we took the feedback and used that to drive our quality improvement efforts," she said.
With clear results. Take DRG 107, for example, coronary bypass without catheterization. In 1992 St. Luke's, a major regional cardiac center, had average length of stay of 10.2 days and average cost per case of $18,000. By June 1996, the length of stay had dropped to 7.2 days, while cost was $15,200.
Of the top 26 DRGs by volume at St. Luke's, 20 are covered by clinical pathways. Of those 20, 18 have seen their average length of stay decline by 12%.
That's largely due to the start of concurrent utilization review of all admissions in February 1992.
"Data drives our continuous improvement process," Fibuch said. St. Luke's extracts data on every patient in the hospital every day. It employs a small cadre of specially trained nurses armed with laptop computers who patrol the hospital and copy data off patient charts. At the end of the day they download the numbers into a large database, which now contains information from more than 100,000 discharges. The data on each patient are analyzed for utilization management and quality indicators while the patient is still in the hospital.
It's called 100% concurrent abstraction, Fibuch said, and St. Luke's has been doing it for four years. "This is a very expensive process, but we think it is worthwhile," he said.
Toigo added: "It's more resource intensive than sampling techniques, but we do have the ability to change the course of action (for the patient) as things come up."
Further, the hospital's Medicare case-mix index of 1.86 indicates that patients' acuity is extremely high, yet the post-discharge mortality rate is consistently below benchmarks at 15 days, 30 days, 90 days or 180 days.
Remarkably, St. Luke's achieved these results while reducing full-time-equivalents and expanding patient volume. It took a hard look at its employment and trimmed about 250 positions from the payroll over several years.
"We called it work redesign," Hastings said. Licensed for 660 beds, the hospital reduced its capacity to 440. "We had enough beds open to meet our patient population needs, but we don't have excess capacity. Of the capacity we're utilizing, we're running at 98% occupancy" for medical acute-care beds, Hastings said. Length of stay is right where they want it to be.
Such information reporting controls and quality management techniques have reaped rich rewards for the hospital, and not just in quality. Financial reports from HCIA indicate St. Luke's has enjoyed a turnaround in the past several years. After posting a net loss of almost $3 million in 1993, the hospital's 1995 net income leaped to $27 million on net patient revenues of $218 million. The operating profit margin for 1995 was 8.4%.
"We also had volume growth," Hastings said. "Frankly, I believe part of it is the quality perception in the community." While St. Luke's is not advertising its quality results to the public, it has prepared a brochure for employers and health plans that compares its volume and outcome data with those of 16 other large Kansas City area hospitals. St. Luke's consistently scores highest in local patient preference polls.
Hastings thinks quality programs are essential to keep healthcare honest: "If providers are not willing to dig in to this whole thing of data and quality, then nobody's going to do it. Otherwise those who do it will come from a nonclinical standpoint."